Molluscum Contagiosum Treatment
Physical removal methods—including cryotherapy with liquid nitrogen, curettage, or excision—are the recommended first-line treatments for molluscum contagiosum, particularly for symptomatic lesions, multiple lesions, or those near the eyes causing conjunctivitis. 1
Treatment Algorithm
For Immunocompetent Patients with Limited Disease
Watchful waiting is reasonable for asymptomatic, limited disease, as spontaneous resolution typically occurs in 6-12 months (though can extend to 4-5 years). 1
Active treatment is indicated when:
- Lesions are symptomatic (painful, itchy, or inflamed) 1
- Multiple lesions are present 1
- Lesions are located on or near the eyelids with associated conjunctivitis 1
- Patient desires treatment to prevent transmission or for cosmetic reasons 1
First-Line Physical Treatments
Cryotherapy with liquid nitrogen achieves complete response in approximately 93% of cases and is highly effective. 1 The goal is to achieve visible freezing extending slightly beyond the lesion margin into normal skin. 1 However, avoid treating sensitive areas (eyelids, lips, nose, ears) due to higher complication risk. 1
Curettage, simple excision, or excision with cautery are equally effective alternatives recommended by the American Academy of Ophthalmology. 1, 2
First-Line Topical Chemical Treatments
10% potassium hydroxide solution has similar efficacy to cryotherapy in children (86.6% vs 93.3% complete response) and confers better cosmetic results due to lower risk of postinflammatory hyperpigmentation. 1
Cantharidin has shown effectiveness in observational studies, with clearance rates ranging from 15.4-100% for molluscum contagiosum. 1, 3 Recent FDA-approved cantharidin 0.7% topical solution (YCANTH™) demonstrated 46-54% complete clearance versus 13-18% with vehicle in phase-3 trials, applied once every 21 days for up to four treatments. 4 A prospective randomized trial showed 36.2% clearance with cantharidin versus 10.6% with placebo. 5
Critical Treatment Principles
Identify and treat ALL lesions, including nascent ones, during the initial treatment session to reduce recurrence risk. 1 Reducing viral load allows the host immune response to eliminate residual virus. 1
For periocular lesions with conjunctivitis, physical removal is imperative, though conjunctivitis may require several weeks to resolve after lesion elimination. 1
Special Populations
Children Under 2 Years
Salicylic acid is contraindicated due to risk of systemic toxicity. 6
Immunocompromised Patients
Multiple large lesions with minimal inflammation should prompt screening for immunocompromised state. 1, 2 Consider dermatology referral for extensive or recalcitrant disease. 1
Treatments NOT Recommended
Imiquimod has not shown benefit compared to placebo in randomized controlled trials and should not be used. 1, 6
Ranitidine has no evidence supporting efficacy for molluscum contagiosum and should not be used. 6
Common Adverse Effects and Cosmetic Considerations
Cryotherapy risks include postinflammatory hyperpigmentation (most common, persisting 6-12 months), erythema, vesicle formation, and burning pain. 1 This is particularly relevant for facial lesions or patients with darker skin tones. 1
Cantharidin adverse effects include pain (7-85.7%), blistering (10-100%), and hyper-/hypopigmentation (1.8-53.3%), though these are typically mild to moderate. 3, 4
Follow-Up
Follow-up is not usually necessary unless conjunctivitis persists or new lesions develop. 1, 2
Prevention Counseling
Avoid direct skin contact with infected individuals, sharing towels/fomites, and communal water exposure (pools, hot tubs). 1 Keep all lesions covered with waterproof bandages if water exposure is unavoidable. 1 Hand hygiene with alcohol-based disinfectant or soap and water is the most important preventive measure. 1